Case/Chronic Condition Management & Shock Loss assessments

Before beginning the online submission process, it is suggested that you view or print a copy of the form, then gather all the information required to complete the whole form. Because of the sensitive nature of the information requested, the information is not saved in your computer or our web server and cannot be retrieved to be finished at another time. Therefore, the form must be completed in a single session. Additionally, the online application limits the amount of time your browser can remain idle. If for any reason you stay on a single page for more than 20 minutes, all information entered will be erased from memory, and will have to be reentered.

If, at any time, you wish to discontinue the submission process, be sure to close your browser to ensure that any data entered is no longer viewable on your computer. All information is erased on your computer, as well as on the Hines & Associates, Inc. server, whenever your browser is closed.

Requester Information

last name

first name

Phone

Group Information

NAME

Plan/policy#

ADDRESS

CITY

STATE
State Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District Of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming

ZIP

Self Insured

Insured Information

last name

first name

insured id #

Claimant Information

Last Name

First Name

Date of birth

Relationship Choose One Child Guardian Parent Self Spouse Step Parent

Phone

ADDRESS

CITY

STATE
State Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District Of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming

ZIP

icd-10 (if Available)

diagnosis

CARRIERS

Carrier Name

Contact Last Name

Contact First Name

Phone

Plan Year

Spec Deductible

Provider Information

Physician Last Name

Physician First Name

Phone

Name of Hospital

Phone

SERVICES REQUESTED

Medical Case Management

Shock Loss/Renewal Reporting

onsite-evaluation

Behavioral Health Case Management

Negotiation/Nurse Review of Medical Necessity

Nurse Review of Medical Necessity

Wellness Prevention Chronic Condition Management

COMMENTS

In this Comments field, list the patient email address and any additional pertinent information not included in the records being attached. A response to your request will be provided via secure email upon completion of the review. Please enter an email address we can use for this purpose.

ATTACHMENT